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Venice, 18 October 2015 Long term outcome of AF ablation in different clinical settings: Hypertrophic Cardiomyopathy Andrea Corrado, MD UOSD Cardiac Pacing & Electrophysiology Cardiovascular Department "Dell’Angelo" Hospital of Mestre, Venice NO CONFLICT OF INTEREST TO DECLARE Prevalence of AF in HCM ! The prevalence of atrial fibrillation in hypertrophic cardiomyopathy patients is high range 18%–22% ! It may be related to atrial dilation and atrial fibrosis, in the setting of remodeling for diastolic dysfunction and mitral regurgitation 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy Effects of AF in HCM ! AF it is often poorly tolerated by HCM patients because of loss of atrial contraction and reduced filling time with rapid ventricular rates. ! AF is associated with increased morbidity and mortality from heart failure and stroke 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy Incidence of TE for AF in HCM ! annual incidence of thromboembolism (stroke and peripheral embolism) in patients with AF were 3.8% 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy OAT for AF in HCM ! patients with HCM have not been included in clinical trials, use of the CHADS-VASC score risk is not recommended ! it is recommended that all patients with AF should receive OAT lifelong 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy Diagnosis of AF in HCM 48-hour ambulatory ECG monitoring every 6–12 months to detect AF should be considered in patients who are in sinus rhythm and have an LA diameter of ≥ 45 mm IIa 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy Major clinical features associated with risk of SCD ! Age ! NSVT ! LV wall thickness ! Family history of SCD ! Syncope ! LA diameter ! Left ventricolat outflow tract obstruction ! Exercse blood pressure response 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy Therapy of AF in HCM ! Current guidelines for management of AF recommend a rhythm control strategy in HCM patients 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy AADs for the managment of AF in HCM ! Antiarrhythmic drugs are often used despite minimal evidence 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy AADs for the managment of AF in HCM Amiodarone should be considered for achieving rhythm control and to maintain sinus rhythm after cardioversion IIa 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy RF ablation for the managment of AF in HCM Catheter ablation for atrial fibrillation should be considered in patients without severe left atrial enlargement, who have drug refractory symptoms IIa 2014 ESC Guidelines on diagnosis and management of hypertrophic cardiomyopathy Catheter ablation for atrial fibrillation in hypertrophic cardiomyopathy patients: a systematic review Ha, HSK et al J Interv Card Electrophysiol. 2015 Nov;44(2):161-70 (Epub 2015 Aug 25) ! 8 studies ! 241 HCM pts underwent AF ablation Results (241 pts) Number of patients Prevalence Maintenance of SR (%) of AADs (%) Hayashi 2014 17 82 47 Santangeli 2013 43 53 76 Derejko 2013 30 53 37 Di Donna 2010 61 67 36 Bunch 2008 33 47 48 Gaita 2007 36 64 23 Kilicaslan 2006 27 70 22 Liu 2005 4 75 23 Results (241 pts) ! The mean follow up 18-19 months ! Efficacy in paroxysmal AF: 71 % ! Efficacy in nonparoxysmal AF: 59 % ! Redo procedures: 43 % ! Pts still requiring AADs: 25 – 36 % Outcomes of non pharmacologic treatment of atrial fibrillation in patients with hypertrophic cardiomyopathy Bassiouny M, et al Heart Rhythm 2015;12:1438–1447 ! 147 HCM pts underwent AF ablation ! 79 catheter ablation ! 68 surgical ablation ! Follow up 36 months Results (after first ablation) 81% 74% 51% 58% 43% 29% Results (major complications) ! Major complications: ! Catheter group 6% 2 PVI stenosis - stent, 1 tamponade, 1 stroke, 1 goin hematoma - transfusion ! Surgical group 18% 3 died (1 sepsis, 1 heparin induced thrombocytopenia, 1 at home - unknown) 3 tamponade, 1 stroke, 1 SVT pulseless, 1 complete AVB, 1 pulmonary embolism, 1 severe mitral regurgitation, 1 pericarditis Results ! On last FU, patients reported symptomatic improvement with decrease in NYHA functional class (from 2.55 to1.14 ). ! NYHA class improved in both patients who had a successful PVI as well as in those who had recurrent arrhythmia. AF became better controlled with decrease in prevalence of persistent AF. Results (predictors of success) ! Male ! Higher baseline EF ! Paroxismal AF ! Short of AF duration ! Lower stage of diastolic dysfunction Impact of Left Ventricular Diastolic Dysfunction on Outcome of Catheter Ablation for Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy Okamatsu H, et al Circ J. 2015;79(2):419-24 ! 22 HCM pts underwent AF ablation ! Median follow up 21 months ! Sinus rhythm was maintained in 59% of patients ! LV diastolic dysfunction was associated with difficulty of rhythm control after ablation Results Atrial fibrillation ablation in patients with hypertrophic cardiomyopathy long-term outcomes and clinical predictors Contreras-Valdes, FM, et al JACC 2015;65:1984–94 ! 40 HCM pts underwent AF ablation ! 64 pts underwent AF ablation without HCM but similar AF characteristics ! Median follow up 54 months Results Conclusions ! efficacy of AF ablation in HCM patients is significantly lower compared with non affected patients ! independent predictors of arrhythmia recurrence: ! higher LV outflow obstruction ! higher baseline left atrial pressure ! higher dilatation of left atrium QTc Interval Prolongation Predicts Arrhythmia Recurrence After Catheter Ablation of Atrial Fibrillation in Patients With Hypertrophic Cardiomyopathy Wen SN, et al Circ J 2015; 79: 1024 – 1030 ! 39 HCM pts underwent AF ablation ! follow up 15 months ! Efficacy 41% of patients ! QTc prolongation resulted to be an independent predictor of arrhythmia recurrence Results Left atrial wall thickness and outcomes of catheter ablation for atrial fibrillation in patients with hypertrophic cardiomyopathy Hayashi H, et al J Interv Card Electrophysiol. 2014 Aug;40 (2):153-60 ! 17 HCM patients vs 34 control patients without heart disease ! age, gender, type of AF, and LA dimension were matched ! the LA wall in the HCM patients was not thicker than that of the matched patients without structural heart disease ! efficacy did not differ between the two groups (53 vs. 56 %) AF ablation in HCM: yes or not? ! Worse results in term of mantainig SR " large atrium " dystolic disfunction " atrial fibrosis AF ablation in HCM: yes or not? ! Worse results in term of mantainig SR " large atrium " atrial fibrosis ! Better results in terms of QoL " pts very symptomatic " AADs poorly efficacy AF ablation in HCM: when? ! Early procedure ! Shorter hystory of AF ! Atrium less then 45 mm ! Less degree of dystolic dysfunction Venice, 18 October 2015 Thank you for attention